Yes, problematic
>We threw in Elizabeth Holmes for a lot less—though one suspects her fatal error was not the fraud itself but the transparency of it, the sheer crudeness of promising blood tests that did not work rather than the more sophisticated approach of selling actual drugs through loopholes so baroque that even their exploitation carries a patina of legitimacy.
What?
>The pharmaceutical equivalent of putting both ketchup and mustard on a hot dog and calling it gourmet—though one suspects the hot dog vendor would display more honest shame about his craft.
Huh?
Yeah, that's quite a stretch of comparison...
Questionable quality control vs brazen fraud
This style of writing is a welcome change from all the AI slop or self promoting blogs out there.
It’s a personal touch without making it all about the author. Long form articles with some humor used to be all I wanted to read on the web.
To be clear, whether or not it is AI prose is beside the point in my opinion. I think this piece is informative and funny but could be edited down significantly, regardless of how it was produced.
Well, according to the principle of lenity, or strict construction, that's exactly how the law is supposed to work.
Strongly disagree with almost everything in this article, but specifically this. The reason people make these choices is not because of slick marketing working against them, it's because the existing process to get medical treatment is paternalistic, hard to navigate and often expensive.
If you want safe and really high quality medical care you should absolutely have a personal physician you have a personal relationship with, who understands your lifestyle, your risk factors for side effects, and your medical needs deeply. How many Americans have that? Maybe a few dozen? The market has responded to just how terrible the existing system is.
The system sucks, but Hims are also terrible, and medical care should not be like Amazon prime.
These are not the same magnitude of sin, particularly since one's shortcomings are large reason for the existence of the other.
Speak for yourself; that is exactly what I want. And anyone else who wants a similar experience should be able to purchase it.
The way I see it, services like Hims are forcing a discussion that needs to have happened a long time ago. If people are willing to rely on them for medicines that can have some pretty serious side effects, what does that say about our existing system that people are eschewing? When you're asking people to choose between being able to afford to eat, and being able to afford something like insulin, why the fuck would you expect the decision making process to be anything otherwise?
Maybe many americans would disagree, right until the moment when they're nearly vomiting their guts out at the pharmacy, waiting for their zofran, which is going to cost them several hundred dollars, just because they're getting a version with a little glucose added so it doesn't taste as bad when you take it.
This article is pure FUD pearl clutching
Hims is like that.
A bit of a tangent: I have this here in the US, through a model called Direct Primary Care. I pay $50/mo for a single provider, unlimited visits / communication, and highly discounted labs. She makes house calls on occasion. This doctor is working solely in my interest, and has little concern of insurance, except to help me navigate that system should I need a specialist, prior authorization, etc.
I do worry that it's sustainable, but I think there must by a way to scale up this practice of the general practitioner working in the interest of the patient.
My previous doctor was part of a large health system, who also happens to be directly associated with the large regional insurance provider whom my employer supplied to me without another choice. Every 8 minute visit centered around insurance and billing, with my health seeming to be a distant second. It seemed every visit had to end in some kind of prescription or referral, arrived at quickly and without much discussion. It quickly became clear they were not working in my interest, and I sought other options, eventually landing on the Direct Primary Care model. Now I have full 1 hour visits, and someone who seeks to understand what is happening for me completely, not through the lens of a payer.
Someone's presumably paying her more than $50/hr, which will burn through your monthly fees pretty quickly. Where's the money coming from?
A lot of these 'concierge medicine' services are set up to deal with mostly people who don't need all that much medical care, beyond relatively brisk access to the doctor in a few rare circumstances. Since they also don't really do much in terms of specialty care, they tend to have fewer Px who need extensive personal care.
That's 420+ patients at $50/m.
Doesn't seem feasible to know them all personally and deeply.
Other revenue would be needed.
But the figures I’ve seen quoted for such service usually begin in the four digits, sometimes five digits, annually.
> I do worry that it's sustainable
200 patients at one hour per is a bit more than a month of 9-5s.
If I visited my GP once per 1.5 months I’d be paying a fuckload more than $50/mo in copayments alone, in addition to my incredible premiums.
Healthcare becomes pretty affordable when you’re not paying for actuaries and other scammers.
I'm at about 1 hour per year with my GP (I guess they can be spending additional time on notes or whatever, but I don't think it's much).
Some of it is that there’s a general breakdown in trust that makes a lot of people think that somebody who shot a healthcare executive is a hero, or that there is little outrage that a lunatic like RFK jr is in charge of HHS. I mean, there are legitimate reasons to think institutions are illegitimate but I think there’s something self-perpetuating about distrust, people find meaning in it. It reminds me of the 1980s and 1990s when there were all the stories right out of Rambo that there were still POW in Vietnam and you’d see those black flags everywhere because it wasn’t patriotic enough to fly an American flag.
I suffered for 25 years from chronic pain that was referred TMJ. I've seen a cardiologist who is fine and all but much of his advice is the exact opposite of what I read on PubMed (and not just one paper on PubMed but 20 or 30 papers.) I've had several psych evals that I learned later were of very high quality for the their time but it took about 45 years for a book to practically jump into my hands at my university library which explained how I'm different from other people. I was annoyed as hell when a sports medicine doctor wrote NAD [1] on my chart when I was complaining about my activities being limited by knee trouble.
I work for a large employer in a state where it is illegal to offer junk insurance. My story was not too different when I was on Obamacare except I was paying what seemed an astronomical amount in premiums. I know a lot of people have it worse.
Looking at the how high the stakes are, I mean, you are all you've got, it's no wonder that people can't look at the limitations of the system with equanimity. The doctors I work accept me being a partner in understanding my conditions and my care but the moment they hear the voice of a professional fibromyalgia sufferer I bet they wish they could quit their job if they didn't have debt for student loans or to start their practice.
A lot of people seem to think "it would be allright if we just got more resources", I wish I could wave a magic wand and let them change places with Michael Jackson. Nobody is doing Elon Musk a favor shooting him up with Ketamine every week as well as other controlled substances. A lot of people just won't take help. I know people with schizophrenia who have no insight into their condition. Others with serious mental health diagnosis who refuse to take any med that isn't a controlled substance. For that matter, families where you get the kids a lot of nice and appropriate stuff for Christmas and you come back in a week and they've trashed all of it.
Having a positive attitude and just some gratitude for being here and the miracle that people have figured out as much they have and that a $10 prescription can cure conditions that were a death sentence just 100 years ago goes a long way. [2] I've personally tried to help a lot of poor people who seemed to have a bottomless pit inside them but if you look at the likes of Elon Musk, rich people can be like that too.
[1] https://www.quora.com/What-does-no-apparent-distress-mean-in...
> They make these choices not because the products are better, but because the entire experience has been optimized to feel more like shopping and less like confronting the mortality and vulnerability that define the human condition. This is what disruption looks like when applied to the oldest human needs: not improvement, but the illusion of improvement
And contrary to what the article claims with hundreds of words of flowery indictment, it is improvement. As everyone on this site should be able to tell you, UX matters, and the medical establishment has some of the most frustrating, unpleasant, and confusing UX of any necessary service.
Of course shady companies are going to get lots of business when all the competition following the law most faithfully provide a broken UX, and the only way to do otherwise is to bend the rules.
However, when I get referrals from OneMedical to specialists like eg sleep apnea, those 3rd party specialists usually have like 8 month waiting lists. So, back to Hims-style online-only providers for that sort of thing.
They’re still a great option if you have other needs, like Prep or stimulants.
A large percentage of people want their doctor to prescribe them antibiotics when they have a virus. It’s been shown that doctors who over-prescribe antibiotics get better patient reviews for example.
Now you have a “better UX” that pops up that gives people exactly what they want. They answer a few questions on a website and they get an antibiotic prescription.
There is no way for the medical establishment to compete with a site that will give people what they want even when it’s harmful to them without even requiring any kind of examination.
In the case of antibiotics, this kind of behavior breeds resistant bacteria that regularly kill people.
In the case of other drugs or combinations of drugs, the risks are usually only to the patient themselves. But the risks are real and patients assume this stuff is regulated.
Are they over-prescribing, or are the others under-prescribing? Comparing how hard it is to get antibiotics as a human with how easy it is to get them for animals (even if there's no evidence of disease) certainly makes one think.
As far as human antibiotic use, the flip side are the colleagues who will tell me that they did a thorough workup on a patient, found no indication for antibiotics, told the patient so to the best of their ability, and got dinged on the insurer's survey or castigated on doctor rating sites. I'm of course only hearing the provider's side of the story, but nobody likes to be told no, even when it's the right answer. (Also insert opioids, stimulants and benzodiazepines into this conversation.)
And none of that has any impact on whether or not we should limit antibiotic overuse in humans.
Doctors certainly aren’t under-prescribing antibiotics if you look at the data.
GLP-1 drugs may be a game-changer for obesity and diabetes, the same way that cholesterol (statin) drugs have greatly improved heart health. Hopefully reversing a long trend of increasing waistbands in developed / developing countries. Unfortunately, America will pay the highest price (including Medicare). I'm all for anything that makes them cheaper, including the many compounding pharmacies currently exploiting the loophole the author takes issue with.
The legit path for compounded semaglutide is buying up Rybelsus, impacting the supply for diabetics. Compounding pharmacies are notoriously shady, and are likely using grey market materials from questionable sources.
They are in general shady, and the Florida pharmacies are notoriously under-regulated. Guess where most of the online dick pill outlets do their compounding?
Are they? Compounding pharmacies are common and boring. If someone hasn't yet used a compounding pharmacy then it's likely they're in very good health -- yay for them!
What's being described doesn't feel like an issue with compounding rather folks setting up shop to peddle questionable drugs.
You can maybe talk about the hollow men of Novo and Lilly, who colluded with PBMs and insurers for most of a decade to push the cost of insulin analogues into the stratosphere, taking billions in profit while people died in agony rationing insulin. (in horrible agony -- blood turning into acid until brain death)
Also recombinant DNA processes for making these meds is pretty mature tech it’s not like some crazy trade secret.
His parents have been doing IV infusions for the past two years, which seem to be having more of a positive impact than anything the health care system did, and now they are about to start peptide therapy, which is something I know little about.
Edit: had to do a quick double check, but the foods that I eat, and don't eat, are specifically for hEDS/ME/CFS brain fog which I believe is IL-1B cytokine related and I think it's plausible that this probably has a crossover to Crohn's. Listing it here as something to consider; A diet of zero sugar and zero fruit, a lot of kale, chia seeds, and pumpkin seeds. I do one meal a day, and an occasional extended water fast. For vitamins I take TUDCA, DIM, and D3.
Prolonged use of steroids can cause dysautonomia which causes a plethora of other issues. So understanding dysautonomia could help. I also use a weak ligand approach to dysautonomia which is unusual with the use of modafinil and amitriptyline.
Low Dose Naltrexone (LDN) is a rather benign medication that's been known to help. There is little downside to trying it - so it can be used as a bit of a diagnostic in addition to treatment. Of course DIY research rules apply.
One of my more out there theories that seems to be quickly gaining traction is that a low dose of GLP-1 agonists can be surprisingly good for autoimmune conditions.
Most of my other peptides are hEDS focused and include VIP, Ipamorelin, Selank/Semax, and BPc157/TB500. Though I really only take the ipamorelin and semaglutide these days. These are a bit more risky but since my alternative is to be very sick I have a different risk tolerance profile compared to most.
Oligopolies colluding to elevate prices of necessities to fatal levels is a product of regulation. In cases like these, incumbent businesses support regulation because it raises barriers to entry for new entrants; this results in oligopoly or monopoly, permitting the extraction of monopoly rents, even when people are literally dying in the streets because they can't afford products like insulin which are extremely cheap to produce.
(Insulin wasn't always cheap to produce, but for 43 years now it's produced by genetically engineered microorganisms, which makes it very cheap. It's a tiny protein, only 51 amino acids, produced from a 110-amino-acid precursor protein.)
Consumers are so alienated that they'll pay out of pocket for a disruptor like Hims, which is doing its best to circumvent the entire system. Sadly, just as there's little government oversight to prevent pharma from becoming monopolistic, there's virtually no regulation on supplements. So you end up with the worst of both worlds; you can either take the $1000 monopoly pill or the $2 gas station pill filled with sawdust and raccoon repellant.
Those complexities may be relevant to other drugs, but not specifically to insulin, which is the case we're discussing here. Nobody needs to recoup their research investment for figuring out how to make insulin cheaply, and insulin prices are extremely far from "the point of maximum efficiency/optimization", which would be where drug companies were charging barely enough to cover the cost of production. Insulin is not regulated as a supplement, it cannot be administered as a pill, it is not sold in gas stations, and no cases of sawdust or raccoon repellent contamination have been reported in insulin.
All that's happening with insulin is that there's an oligopoly that's colluding to extract monopoly profits, which they can do precisely because regulation prevents biology students from hacking together insulin-producing yeasts over the weekend and selling the insulin to whoever is willing to risk it. That same regulation is what prevents Harbor Freight from importing insulin by the case from any of the dozens of other countries where it costs a tenth of what it costs in the US.
https://old.reddit.com/r/AskChina/comments/1j9zf2u/chinese_i... says of China, "I checked and found that rapid-acting insulin is $4 per bottle, long-acting insulin is $10 per bottle, and other brands of insulin cost between $5 and $8." So why does it cost US$100 per bottle in the US? You'd think you could make a big profit importing Chinese insulin, no? But regulations make it difficult to import that insulin from China, so difficult that incumbents can extract US$100 per bottle in monopoly rents.
> but these enforcement efforts feel perpetually behind the curve in an economy where regulatory complexity has become a competitive advantage
The only way for "regulatory complexity" to become a "competitive advantage" is for there to be very high levels of regulation.
I think that the solution isn't specifically more regulation, or less regulation, or more regulators (which would just compound the problem), but better regulation. Law should be treated like code - as a liability (not an asset), but one necessary to accomplish a purpose, and so written as carefully and simply as possible.
Where's our team of pen-testers looking to find holes in the draft of a new law? Our Unix-philosophy-adjacent lawyers proclaiming that "less is more" and striving for composability in separate laws instead of bundling everything together? Our git forge for legal documents where the public can view and comment on the legal system (even if actually making changes is more complicated)?
Software engineering and the law could learn so much from each other - it's a shame there's so little cross-pollination.
No masters except the patients that are literally being empowered to make choices about their medical care and are paying a substantial premium (in many cases) to do so.
I would happily be empowered by my doctor and UnitedHealthcare instead, but sadly that’s not on the table.
Try getting tretinoin from a real doctor; I’ve been written prescriptions multiple times, never once succeeded in actually getting it, because insurance is a fucking nightmare. And I’m not on a cheap plan.
Also note that the compounded semaglutide is superior because it comes in adjustable dose vials, unlike the pens. But I’m sure the author would claim that taking a smaller dose to reduce side effects is “a dangerous and unproven approach to medicine that puts patient lives on the line purely for profit”.
So if you're paying for it with Hims why wouldn't you be willing to pay for the medication the doctor prescribes to you if the insurance company is refusing to pay for it?
GLP-1s are a miracle drug, people want it so will do what they must to get it. Unfortunately for many of them they cannot afford the $1,000 a month price tag that comes with legitimacy. On top of that, regular doctors make you jump through hoops to get it, having to see the exercise and diet department of whatever hospital group they belong too. this adds hundreds / thousands to the cost.
Let people have what they want. Hims parasitized the process but I don't blame them for it. They gave the people what they wanted and made a profit at the same time.
Adults should be empowered to make their own health care decisions but unfortunately so many of those decisions are made either by insurance companies or the attractive sales reps that frequent the doctor offices. GLP-1's, testosterone, peptides, whatever, remove the gate keepers and allow the free market to compete. The fact that you can go to jail for ordering a 10ml bottle of test cyp over the internet is madness. I rarely go to the doctor now, except for things that are clearly beyond my limits, xrays, colonoscopy etc. For everything else there is the internet and chatGPT. GLP-1s, peptides, steroids, even anti biotics, almost everything you want can be found if you look. The way it should be. I even order my own labs and have chatGPT interpret them for me.
I'm in the best shape of my life at 46 and haven't been to a non hormone doctor except for specialists in several years. Last time I went to the doctor I told them I wanted GLP-1s and they said no, I would have to go and see their diet department. I told them if they did not prescribe them I would just get them online but I would prefer to use them under the supervision of a dr. They just shrugged.
I'm on cycle currently but when I am done and coasting again I am going to hop on metformin to take a crack at stabilizing my liver levels caused by fatty liver before I took control of my own health. Because... why not? Think a doctor would prescribe this?
Let people be the decision makers of their own health. I'm not knocking doctors, they are often highly intelligent people doing good work but their power as gatekeepers does not come with neutrality and they are often beholden to their own bottom line as opposed to the patients well being.
They don’t care that it helps people stick to their healthy diets and get better. They need these people to bear the stigma of the gluttony.
If you go on a fad diet, lose weight, then gain it back when you stop, well, you haven't really lost anything other than time.
If you go on semaglutide, lose weight, then gain it all back when you stop, you're out thousands of dollars, I'm out money when my insurance premium goes up to support the new expensive drugs, and you might have permanent health complications (rare though they might be).
I haven't heard any success stories of people keeping the weight off after they stop taking it, though I've heard plenty of people gaining everything back, and being miserable from the side effects while they were on it.
If semaglutide worked as a stopgap to help you get to the point where you could manage your weight on your own, I think it would be hard to argue with it. So far, though, I've had people tell me that it should be treated as just another vitamin supplement that you'll be on for life, albeit one that costs $12k a year or whatever the case may be.
It's a good thing then that insurance won't pay for it and these services don't even bill insurance.
It's also not $12k a year for the generic, it's around $1200 a year. The drug isn't that expensive to make, the brand is just jacking up the price.
The "ooo scary medicine!" thing doesn't really work for people who are already sick and suffering. That ship has sailed.
Does obesity have permanent health complications and cost you extra in premiums?
I should also add that those pharmacies, if they are based on the United States, invariably have a licensed provider in there signing off (they would be illegal otherwise).
Regarding the licensed provider, you are absolutely correct, I always get an email signed by whatever doctor works with the site. Its a rubber stamp but its does provide legality.
I believe many obtained ivermectin through similar channels despite it being a prescription drug
Ivermectin is available there as well. Never tried it though. Actually thinking of taking a mild course though. Why not?
No association with it but have used it multiple times.
https://allfamilypharmacy.com/
Mods if this is not ok, my apologies
They're also under prescribed for things like appendicitis.
As with most products, companies need a way to make promises to consumers about what's in the products. The only way the consumers will believe those promises is if the consequences for lying are severe. Clearly room for improvement here, maybe some of these 3rd party certification labs can start putting their seals on medications too.
The article mentions that medication from China isn't part of an FDA approved supply chain, but as a consumer I don't really care about that. I'd rather have mass spectrometry data on the side of the tin than the FDA's blessing.
Does the telemedicine appeal to people because they want to avoid embarrassment, or because they know that traditional doctors will schedule you for an appointment three months out just to say “have you tried getting better sleep, losing 30 pounds, and reducing stress?”
Don't forget that 3 month out appointment is probably 15 minutes long with a 30 min office wait which you'll then inevitably fight insurance over (Hims doesn't bill insurance either)
Telemedicine isn't a panacea, but in a system with major constraints on doctor bandwidth and where in-person visits are very expensive, it's extremely helpful. And yeah, a lot of that is because so often the solution is as you said -- get more sleep, eat better, maybe work out a little, reduce your stress. I'd much rather have a quick 15 minute call to be told that, instead of having to take several hours off work to go visit the doctor in person.
If people could just “reduce stress” on a whim, they would. Having a doctor tell you reduce stress will actually increase stress.
There's a lot of shame in society around all of these issues, and it's really appealing to a lot of Men to be able to spend an extra $100-200 to not have to have a conversation that embarrasses them with a Doctor who may know their wife, friends, or otherwise may be part of the community. That's the value proposition of Hims; a $200 fee to maintain the illusion of their inherent virility and masculinity. A lot of Men will happily pay that, and have the disposable income to do so.
Hair loss is sucky, sure, but in the grand scheme of medicine it's nothing. Erectile dysfunction sucks, but are you old? That's just the name of the game.
I lost my testicles to cancer (yippee) and you would be shocked how difficult it is to just... get testosterone. My fundamental bodily functions no longer exist, but I'm technically fine so... I guess that's okay? Like I'm not dying, and quality of life is in the eye of the beholder or something. Never mind I'm literally castrated, like physically. And they'll talk your ear off about side effects.
Side effects? What about primary effects? Man, I have no balls! Everything sucks and I wake up feeling like I've been run over by a truck!
"The shameful doctor visits."
The what? Seriously, doctors in urology and related fields have seen guys whose dicks haven't just malfunctioned, they were BLOWN OFF, so shame really isn't a factor here!
And I know full well I’m paying more than I should. One of these days I’ll look for a cheaper alternative.
Perhaps HN is full of people with high digital literacy, relatively high reasoning ability etc. People like this can benefit from the service.
The article's core point is that Hims uses unethical marketing. Maybe the HN crowd is privileged: people here may be able to resist marketing.
The article's unstated point is that many people who use Hims would be better off not using it.
HN people tend to be wealthy tech workers. I'm not sure how many people here know about the brutal conditions outside their cozy tech bubble.
There are tens of millions of Americans with low cognitive ability, low digital literacy, high susceptibility to advertising, high stress, poor health, and demeaning jobs - all at the same time.
Many of these unfortunate people spend pretty much their whole lives bouncing around from scam to scam. At age 15 they get exploited by an older boyfriend. At age 26 they get exploited by a for-profit college.
Then at age 45 they get exploited by unethical pharma companies. Like Hims.
The healthcare industry spends a lot of time dealing with this population. Many of these people tend to be "frequent flyers" of government-run programs. People who work in hospitals understand these unfortunate people intimately. When those hospital workers make laws, they spend a lot of time thinking about how to protect these people. Then Hims come along and targets them specifically.
The article's point is that Hims exploits vulnerable people. And I agree.
Honestly, this was way better than using insurance for a physician visit. Half the time you go to the doctor, you already know what they're going to tell you.
I could be wrong, but I believe this system was first made legal during COVID. Despite all the pearl clutching, it works exceptionally well, and should have been legal earlier.
htrp•4h ago